Family presence in Canadian PICUs during the COVID-19 pandemic: a mixed-methods environmental scan of policy and practice

Jennifer Ruth Foster; Laurie A. Lee; Jamie A. Seabrook; Molly Ryan; Laura J. Betts; Stacy A. Burgess; Corey Slumkoski; Martha Walls; Daniel Garros

doi:10.9778/cmajo.20210202

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Figure 1:
Stated reasons for granting exceptions to restrictions, where an exception was an increase in the number of family members present at a single time, or increased frequency of switches (n = 24 respondents).

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Table 1:

Characteristics of Canadian PICUs (n = 19)^*

Characteristic	No. (%)
Hospital type
Stand-alone children’s hospital	5 (26)
Children’s health unit in a larger, mixed hospital	11 (58)
Women and children’s hospital	3 (16)
PICU type
Medical–surgical	11 (58)
Level 2 medical–surgical^†	2 (11)
Cardiac	2 (11)
Mixed medical–surgical–cardiac	6 (32)
No. of beds
< 10	5 (26)
10–19	10 (53)
≥ 20	4 (21)
Ages admitted, yr
Birth to 16	2 (11)
Birth to 17	3 (16)
Birth to 18	14 (74)

Note: PICU = pediatric intensive care unit.
↵* Information provided by respondents from each PICU.
↵† Units providing single-organ support and short-term invasive mechanical ventilation only.

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Table 2:

Family presence policies early in the COVID-19 pandemic (March–May 2020) for all Canadian PICUs — results of literature search^*

Hospital, city, province	Policy information source	Document type(s)	No. of people at bedside		Switching practice to enable second parent or support^†	Approach to minor-age siblings	Approach to other non-parent family and visitors^‡	Response to family or visitors with infectious symptoms or risk^§	In-hospital mobility^¶
Hospital, city, province	Policy information source	Document type(s)	Patients without SARS-CoV-2 infection	Patients with confirmed or suspected SARS-CoV-2 infection	Switching practice to enable second parent or support^†	Approach to minor-age siblings	Approach to other non-parent family and visitors^‡		In-hospital mobility^¶
Janeway Children’s Health and Rehabilitation Centre, St. John’s, Newfoundland and Labrador	Health authority	Website, social media	NS	NS	NS	Not allowed or only at end of life	Not allowed	NS	NS
IWK Health, Halifax, Nova Scotia	Hospital	Website	1	NS	NS	Not allowed or only at end of life	NS	Screened	NS
CHU de Québec–Université Laval, Québec City, Quebec	Hospital	Website	1	NS	NS	Not allowed or only at end of life	Not allowed	NS	NS
CIUSSS de l’Estrie–CHU Sherbrooke, Sherbrooke, Quebec	Health authority	Website	NS	NS	NS	NS	NS	Not allowed	NS
Montreal Children’s Hospital; Montréal, Quebec	Hospital	Website	2 (strict)	NS	Unnecessary	Not allowed or only at end of life	Not allowed	NS	NS
CHU Sainte-Justine, Montréal, Quebec	Hospital	Website	2 (strict)	NS	Unnecessary	Not allowed or only at end of life	Not allowed	Not allowed	NS
Kingston Health Sciences Centre, Kingston, Ontario	Hospital	Original policy, website	NS	NS	NS	Not allowed or only at end of life	Not allowed	Screened	NS
Children’s Hospital of Eastern Ontario, Ottawa, Ontario	Hospital	Website	2 (strict)	NS	Restricted times or frequencies	Not allowed or only at end of life	Not allowed	Screened	NS
The Hospital for Sick Children, cardiac, Toronto, Ontario	Hospital	Website	1	NS	NS	Not allowed or only at end of life	Not allowed	Screened	NS
The Hospital for Sick Children, medical–surgical, Toronto, Ontario	Hospital	Website	1	NS	NS	Not allowed or only at end of life	Not allowed	Screened	NS
McMaster Children’s Hospital, Hamilton, Ontario	Hospital	Website	NS	1	NS	NS	NS	NS	NS
Children’s Hospital–London Health Sciences Centre, London, Ontario	Hospital	News release	1	NS	NS	Not allowed or only at end of life	Not allowed	Not allowed	NS
Children’s Hospital–Health Sciences Centre, Winnipeg, Manitoba	Hospital	Website	1	NS	NS	At manager’s discretion	NS	NS	NS
Jim Pattison Children’s Hospital, Saskatoon, Saskatchewan	Health authority	Original policy, website, news release, poster	1	1	Not allowed	Not allowed or only at end of life	Not allowed	Not allowed	Not allowed to leave PICU room
Stollery Children’s Hospital, cardiac, Edmonton, Alberta	Health authority	Original policy, website	NS	NS	NS	Not allowed or only at end of life	NS	Not allowed	NS
Stollery Children’s Hospital, medical–surgical, Edmonton, Alberta	Health authority	Original policy, website	NS	NS	NS	Not allowed or only at end of life	NS	Not allowed	NS
Alberta Children’s Hospital, Calgary, Alberta	Health authority	Original policy, website	NS	NS	NS	Not allowed or only at end of life	NS	Not allowed	NS
BC Children’s Hospital, Vancouver, British Columbia	Hospital	Website	2 (strict)	NS	Unnecessary	Not allowed or only at end of life	NS	Screened	NS
Victoria General Hospital, Victoria, British Columbia	Health authority	Website	1	1	Restricted times or frequencies	Not allowed or only at end of life	NS	Not allowed	NS
No. not specified (%)	–	–	7 (37)	16 (84)	13 (68)	2 (11)	9 (47)	5 (26)	18 (95)

Note: NS = not specified, PICU = pediatric intensive care unit.
For full data, see Appendix 4, available at www.cmajopen.ca/content/10/3/E622/suppl/DC1.
↵* Abstracted and abbreviated from publicly accessible documents.
† Refers to a PICU or hospital practice in which the number at the bedside is limited to enable 1 caregiver to leave and be replaced by a different caregiver. In this table, switches were designated as “unnecessary” if both parents or 2 caregivers could be present at the same time.
↵† Including siblings over age 18 years.
↵§ Including respiratory infectious symptoms or suspected SARS-CoV-2. ”Screened” indicates that family members were screened for infection, without indication of the action taken if a visitor screened positive.
↵¶ Refers to whether caregivers were allowed to leave the PICU room and move around the hospital for any reason, including accessing basic needs.

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Table 3:

PICU family presence policies — survey responses (n = 24)^*

Family presence policy	No. (%) of respondents

	Before the pandemic	March 2020		August–December 2020

		Patients without SARS-CoV-2 infection	Patients with confirmed or suspected SARS-CoV-2 infection	Patients without SARS-CoV-2 infection	Patients with confirmed or suspected SARS-CoV-2 infection
Shared policies between PICU and all pediatric care areas

Yes	11 (46)	20 (83)

No	7 (29)	3 (13)

Unsure	6 (25)	1 (4)

Agreement, no. of pairs (% agreement)^†	2 (50)	5 (100)

No. of support people at bedside

1	0 (0)	21 (88)	23 (96)	5 (21)	12 (50)

2 (strict)	8 (33)	3 (13)	1 (4)	19 (79)	12 (50)

2 (flexible)	11 (46)	0 (0)	0 (0)	0 (0)	0 (0)

Unlimited	5 (21)	0 (0)	0 (0)	0 (0)	0 (0)

Agreement, no. of pairs (% agreement)^‡	5 (0)	5 (80)	5 (100)	5 (100)	5 (60)

Switches to enable other parent’s presence^§

Unnecessary (multiple visitors permitted)	24 (100)	3 (13)	1 (4)	19 (79)	12 (50)

Not allowed	0 (0)	7 (30)	13 (57)	0 (0)	3 (13)

Any time	0 (0)	4 (17)	2 (9)	1 (4)	2 (8)

Restricted times or frequencies	0 (0)	9 (39)	7 (30)	4 (17)	7 (29)

Agreement, no. of pairs (% agreement)^‡	5 (100)	4 (50)	4 (75)	5 (100)	5 (40)

Timing of parental presence

24/7	13 (54)	19 (79)	22 (92)	20 (83)	23 (96)

Parents always allowed, but only 1 may stay if sleeping	6 (25)	2 (8)	1 (4)	2 (8)	1 (4)

Parents must leave overnight	2 (8)	1 (4)	1 (4)	0 (0)	0 (0)

Parents must leave during rounds or handover	3 (13)	2 (8)	0 (0)	2 (8)	0 (0)

Agreement, no. of pairs (% agreement)^‡	5 (80)	4 (80)	5 (100)	5 (80)	5 (100)

Nonparent family members and visitors may switch into bedside^¶

Unnecessary (family and visitors unlimited)	6 (25)	0 (0)	0 (0)	0 (0)	0 (0)

Not allowed	0 (0)	23 (96)	23 (96)	15 (65)	19 (83)

Any time	12 (50)	0 (0)	0 (0)	3 (13)	0 (0)

Restricted times or frequencies	6 (25)	1 (4)	1 (4)	5 (22)	4 (17)

Agreement, no. of pairs (% agreement)^‡	5 (60)	5 (100)	5 (100)	4 (50)	4 (50)

Sibling presence

Unrestricted	12 (50)	0 (0)	0 (0)	1 (4)	0 (0)

Not allowed, or only at end of life	1 (4)	24 (100)	24 (100)	17 (71)	23 (96)

With restrictions (e.g., time, duration, age)	9 (38)	0 (0)	0 (0)	6 (25)	1 (4)

At RN discretion	2 (8)	0 (0)	0 (0)	0 (0)	0 (0)

Agreement, no. of pairs (% agreement)^‡	5 (80)	5 (100)	5 (100)	5 (100)	5 (100)

Note: PICU = pediatric intensive care unit, RN = registered nurse.
↵* Unless otherwise indicated.
↵† Physician chief and operations manager pairs from the same unit who did not indicate “unsure.”
↵‡ Physician chief and operations manager pairs from the same unit for which both provided an answer to the given variable.
↵§ Early pandemic: n = 23.
↵¶ Mid-pandemic: n = 23.

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Table 4:

PICU family presence practices — survey responses (n = 24)^*

Family presence practice	No. (%) of respondents

	Before the pandemic	March 2020		August–December 2020

		Patients without SARS-CoV-2 infection	Patients with confirmed or suspected SARS-CoV-2 infection	Patients without SARS-CoV-2 infection	Patients with confirmed or suspected SARS-CoV-2 infection
Rounds practices^†

In-person	24 (100)	13 (59)	5 (23)	21 (95)	7 (33)

Virtual or telephone	0 (0)	5 (23)	8 (36)	1 (5)	7 (33)

Nonparticipation	0 (0)	4 (18)	9 (41)	0 (0)	7 (33)

Agreement, no. of pairs (% agreement)^‡	5 (100)	3 (66)	3 (33)	4 (100)	3 (66)

Rounds location^§

Adjacent to room (e.g., bedside)	24 (100)	17 (74)	16 (70)	22 (100)	21 (100)

Distant location (e.g., conference room)	0 (0)	6 (26)	7 (30)	0 (0)	0 (0)

Agreement, no. of pairs (% agreement)^‡	5 (100)	4 (100)	4 (75)	4 (75)	3(100)

Ability to leave PICU room^¶

Unrestricted	24 (100)	17 (71)	0 (0)	–	–

Not allowed to leave	0 (0)	0 (0)	7 (29)	–	–

Restricted: toilet	0 (0)	1 (4)	11 (46)	–	–

Restricted: stress/procedures	0 (0)	0 (0)	4 (17)	–	–

Restricted: eating	0 (0)	0 (0)	2 (8)	–	–

Encouraged not to leave room, not mandated	0 (0)	6 (25)	3 (13)	–	–

Agreement, no. of pairs (% agreement)^‡	5 (100)	5 (100)	5 (80)	–	–

Ability to leave hospital^¶

Unrestricted	24 (100)	21 (88)	3 (13)	–	–

Restricted frequency (e.g., once per shift, once per day)	0 (0)	0 (0)	4 (17)	–	–

Restricted: smoking	0 (0)	1 (4)	5 (21)	–	–

Restricted: switches	0 (0)	2 (8)	7 (29)	–	–

Never	0 (0)	1 (4)	8 (33)	–	–

Agreement, no. of pairs (% agreement)^‡	5 (100)	5 (80)	5 (60)	–	–

Note: PICU = pediatric intensive care unit.
↵* Unless otherwise indicated.
↵† Early pandemic: n = 22; mid-pandemic: n = 22 respondents for patients who tested negative for SARS-CoV-2, n = 21 for patients with confirmed or suspected SARS-CoV-2 infection.
↵‡ Physician chief and operations manager pairs from the same unit for which both provided an answer to the given variable.
↵§ Early pandemic: n = 23; mid-pandemic: n = 22 for patients who tested negative for SARS-CoV-2; n = 21 for patients with confirmed or suspected SARS-CoV-2 infection.
↵¶ Respondents could indicate more than 1 reason for leaving (e.g., toilet, eating, switches and smoking).

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Table 5:

Approach to policy exceptions and decision-making authority — survey responses (n = 24)

Factor	No. (%) of respondents
Approach to policy exceptions^*
Exceptions enabled by policy	10 (42)
Processes understood but not formalized	4 (17)
No initial policy or process, but developed over study period	7 (29)
No policy	3 (13)
Agreement, no. of pairs (% agreement)^†	5 (100)
Decision-making authority
PICU (physician, manager or charge nurse)	9 (38)
Hospital director	8 (33)
Infection prevention and control or emergency operations	6 (25)
Hospital executive	1 (4)
Agreement, no. of pairs (% agreement)^†	5 (40)

Note: PICU = pediatric intensive care unit.
↵* Exceptions referred to enabling deviation from policy in certain circumstances. Examples of exceptions were: allowing more people at the bedside; allowing siblings; allowing more frequent switches of parents or other family members.
↵† Physician chief and operations manager pairs from the same unit for which both provided an answer to the given variable.

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Table 6:

PICU in-room masking requirements and screening for parents and support people — survey responses (n = 24)

Factor	No. (%) of respondents

	March 2020		August–December 2020

	Patients without SARS-CoV-2 infection	Patients with confirmed or suspected SARS-CoV-2 infection	Patients without SARS-CoV-2 infection	Patients with confirmed or suspected SARS-CoV-2 infection
Masking in patient room

Always	4 (17)	11 (46)	10 (42)	15 (62)

Never	17 (71)	11 (46)	8 (33)	3 (12)

When a health care provider is present	2 (8)	2 (8)	6 (25)	6 (25)

If child is infectious	1 (4)	NA	0 (0)	NA

Agreement, no. of pairs (% agreement)^*	5 (80)	5 (100)	5 (80)	5 (80)

SARS-CoV-2 screening for parents and support people^†

Preadmission questionnaire	20 (83)	–	–	–

Hospital or PICU entry screening questionnaire	20 (83)	–	–	–

Daily PICU symptom screening	8 (33)	–	–	–

Temperature check	3 (13)	–	–	–

Admission swab	1 (4)	–	–	–

Agreement, no. of pairs (% agreement)^*	5 (60)	–	–	–

Note: NA = not applicable, PICU = pediatric intensive care unit.
↵* Physician chief and operations manager pairs from the same unit for which both provided an answer to the given variable.
↵† Respondents could choose more than 1 screening method.